Fields marked with * are mandatory.
1. Personal Information
Title
Unspecified
Dr
Miss
Mr
Mrs
Ms
First name *
Last name *
Date of birth *
DD
MM
YYYY
Gender
Unspecified
Male
Female
Non-binary
In another way
Prefer not to say
Please enter your postcode and click Get Address
Home address *
Town or City
County
Postcode *
Country
Home telephone
Mobile
Email *
Please describe your ethnicity?
Not stated
White - English, Welsh, Scottish, Northern Irish, British
White - Irish
White - Gypsy or Irish Traveller
White - Other
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Other Mixed
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Chinese
Asian or Asian British - Other Asian
Black or Black British - African
Black or Black British - Caribbean
Black or Black British - Other Black
Other Ethnic Group - Arab
Other Ethnic Group - Any Other Ethnic Group
Please select the option which best describes your sexuality:
Not Stated
Heterosexual or Straight
Gay
Lesbian
Bi-Sexual
None of the above
Prefer Not to Say
2. Additional Information
Special postal requirements
Preferred Language
Interpreter
Large Print
Audio tapes
Braille
Other (please list in ‘Notes’ section)
Languages
Preferred Language
Interpreter Needed
Do you consider yourself to have a disability / long term health condition?
No
Yes
A sensory disability
A physical disability
A learning disability
A mental health problem
Any other special need (please list in the 'Notes' section)
Areas of Interest
Adult Social Care
Cancer
Children's and Young People services
Chronic Kidney disease
Dermatology
Dementia
Diagnosis process and services
Diabetes
Digital Technology
GPs
Health and Care estates / Location of Services
Health and Care closer to home
Health and care in the community
Health and care workforce
Mental Health
Opthalmology
Orthopaedic
Pharmacies
Population Health (improving the health and wellbeing of communiities)
Prevention
Residential Care
Self Care
Urgent and Emergency Care
Other support services (please list in ‘Notes’ section)
About you
I have dependents under 16
I am a Carer
I am a member of voluntary or community organisation
I am a Governor at an organisation (health or education)
How did you hear about the panel?
MES Recruitment 2019
Online Application
Public meetings
Public consultation mailing
Other (please list in 'Notes')
3. Review
Last Used Services
Title
First name
Last name
Date of birth
Gender
Address
County
Postcode
Country
UK
Home telephone
Mobile
Email
Please describe your ethnicity?
Please select the option which best describes your sexuality:
Languages
Special postal requirements
Do you consider yourself to have a disability / long term health condition?
Areas of Interest
About you
How did you hear about the panel?
4. Finish
*
To agree to become a Residents’ Health Panel member of North London Partners in health and care please sign below. The information you provide us will only be used for matters pertaining to the Residents’ Health Panel. Our privacy notices and your rights can be viewed via:
www.northlondonpartners.org.uk
and
https://www.membra.co.uk/privacy-policy/
The data you supply will be used only to contact you about the Trust, membership or other related issues and will be stored in accordance with the current Data Protection Act. Please click
here
for full details.
You have the right to withdraw consent at any time by sending an email at:
iuliana.dinu@nhs.net
Please tick here if you consent to your details being added to the Public Register.